We performed laparoscopic ileocaecal resection for haemorrhagic caecal cancer, which was identified because of melaena, on the 8th day after acute myocardial infarction, and we obtained good outcomes. To our knowledge, no previous article has reported that laparoscopic surgery was performed at such an early period after acute myocardial infarction.
Surgery immediately after an acute myocardial infarction should be avoided . However, in this case, the patient could not start eating because of melaena, and there was no prospect of discharge from the hospital. Since the cause of the bleeding was a malignant tumour and there was concern that the tumour would progress if surgery was postponed, surgery was unavoidably performed immediately after myocardial infarction.
There are cases in which abdominal surgery must be performed immediately after myocardial infarction. Regarding surgery for oncological emergencies caused by bleeding from colorectal cancer, like in the current case, we consider that laparoscopic surgery has many advantages over open surgery for four reasons from the viewpoint of preventing intraoperative complications and postoperative cardiac complications.
First, laparoscopic surgery has a lower risk of bleeding than open surgery. Surgery immediately after acute myocardial infarction often requires the continuation of antiplatelet drugs , with the attendant risk of increased bleeding. In the current case as well, clopidogrel was replaced with heparin which was discontinued on the day of surgery, but bufferin was continued and surgery was performed. Laparoscopic surgery causes less abdominal wall destruction and generally tends to cause less bleeding than open surgery . It has been reported that compared to open surgery, laparoscopic gastrointestinal surgery for patients receiving antiplatelet or anticoagulant drugs can be safely performed without increasing the risk of bleeding . In addition, a small amount of bleeding precludes the use of a large amount of fluid replacement or blood transfusion which can lead to congestive heart failure. In this case, the intraoperative bleeding was as small as 35 ml, and blood transfusion was not required.
The second reason is that there is less pain with laparoscopic surgery. Postoperative pain has been reported to cause elevated blood pressure . Since hypertension is considered a risk factor for cardiac rupture after acute myocardial infarction , good control of postoperative pain may contribute to a reduced risk of cardiac rupture. In this case, opioids were used for analgesia, with typical doses, and the patient did not develop marked hypertension that required additional postoperative antihypertensive drugs.
The third reason is that the increase in inflammatory cytokines, such as IL-1β and IL-6, is smaller in laparoscopic surgery than in open surgery. A study showed that laparoscopic surgery for RS rectal cancer resulted in a smaller increase in inflammatory cytokines (IL-1β and IL-6) and CRP (induced by these cytokines) compared with open surgery . In addition, a report revealed that laparoscopic surgery is associated with a smaller increase in IL-6 compared to open surgery . Inflammatory cytokines have been reported to increase the risk of acute heart failure and lethal ventricular arrhythmias, which are cardiac complications of acute myocardial infarction [2,3]. Therefore, by selecting laparoscopic surgery in which the increase in inflammatory cytokines is relatively suppressed, it is possible to suppress cardiac complications such as acute heart failure and fatal ventricular arrhythmia.
The fourth reason is that the postoperative intestinal function recovers quickly. Postoperative intestinal function is said to be restored faster in laparoscopic surgery than in open surgery . If the intestinal function recovers early, it is possible to promptly resume oral intake and medications. In our case, all drugs including clopidogrel could be resumed orally from POD1.
The limitation of this case report is that there was only one case, without comparative cases. Therefore, there is no strong evidence of the superiority of laparoscopic surgery over open surgery immediately after acute myocardial infarction. However, accumulating a large number of similar cases is difficult, and it is necessary to consider through such case reports.
For oncological emergencies due to bleeding from colorectal cancer that occur immediately after acute myocardial infarction, laparoscopic surgery may be an excellent method in terms of preventing intraoperative complications and postoperative cardiac complications.